Male circumcision: How the nonsurgical method works

Clinical officers circumcise a client at a hospital in Najeera. File Photo

What you need to know:

Medical male circumcision is being promoted as one of the key HIV prevention strategies. While the procedure has largely been conducted surgically, new nonsurgical options such as the use of PrePex, are being used. We explore its benefits.

For a long time, Bruno Albert Murekye was not comfortable with his foreskin. The girls he dated were particularly concerned about its hygiene.
Over time, the urge to undergo circumcision was always on his mind. But he feared the pain that comes with the surgery. Despite this, in August 2012, he made up his mind and decided to undergo the procedure.

What is circumcision?
Circumcision refers to the removal of the foreskin of a male. Dr William Lubega, an HIV/Aids specialist at the Infectious Diseases Institute at Mulago hospital explains that the conventional procedure, surgical circumcision involves opening up of the foreskin, which is separated from the glands. During the procedure, anaesthesia is administered in the area around the foreskin, to help the body lose sensation or pain when the skin is being cut off and then sewed to the gland (a cell producing secretion).

The PrePex option
But Murekye used a relatively new method known as PrePex. It is a medical device developed to facilitate nonsurgical medical male circumcision for adults as part of a comprehensive HIV prevention strategy in Sub-Saharan Africa.
Murekye explains how the procedure was carried out on him: “The doctors used two rubber rings, one was fixed inside the foreskin, and the other outside to block blood from flowing to the foreskin. The foreskin then moved off gradually and it took seven days for the area to dry up.”

“After it dried, the rubber rings were removed. Fixing and removing the PrePex rings took less than five minutes. I only waited to heal,” Murekye says.
The procedure was carried out in Rwanda, where both PrePex and surgical procedures are carried out for free.

Murekye says: “I feel the difference after circumcision. Before I did it, it used to itch inside the foreskin and I experienced some infections that would cause the penis to smell. Now I do not have to worry about anything,” he adds.

Painless procedure
Dr Leon Ngeruka is a PrePex specialist at the Prepex Center of excellence at the Rwanda Military Hospital. He explains that this method is painless.
“The only pain felt is when you get an erection. You might not see a single drop of blood during fixing and removing of the rubber rings, including the healing process. The healing process takes seven days with the rings on, and after removing them, you will need another 21 days to cure and start engaging in sexual intercourse,” he says.

How Prepex works
Dr Lubega says PrePex is a single-use device, comprising of four elements: a placement, inner and elastic rings, and a verification threat.
“When placed on the penis, it stops the flow of blood and oxygen to the foreskin tissue, initiating tissue death.

“The dead tissue naturally detaches itself, or is easily removed after seven days,” says Dr Lubega.
He says the bloodless procedure can be done in non-sterile settings, in less than five minutes, without the need to use anaesthesia.
Dr Ngeruka says after the dry or dead skin has been removed, one is given antibiotics for the first three days.

“You are also given instructions on how and what to use to clean the penis in order to avoid infection. Warm water with little salt is what we usually recommend,” he adds.
The PrePex device was first developed in 2009, and the Ministry of Health has endorsed it as one of the options to increase coverage of medical male circumcision countrywide.

Dr Lubega says the aim is to have at least 20 million men in 14 Sub-Saharan African countries, including Uganda circumcised by the end of 2015.
In Uganda, an estimated 700,000 men have so far been circumcised through the safe medical male circumcision programme.

Health experts say rapid roll out of medical circumcision is crucial to reducing the rate of spread of HIV/Aids in countries with generalised epidemics and low rates of medical circumcision.
Murekye says after undergoing circumcision, he avoids wearing tight-fitting underwear, in order to facilitate quick healing and avoid unnecessary erections that would lead to painful experiences.
Dr Lubega says one should be aware of the inconvenience of having to move around with the device for seven days, without removing it.
PrePex is being viewed as an alternative for men who fear the surgical procedure.

Comparing the surgical and PrePex circumcision methods, Dr Lubega says: “PrePex is much easier to perform, with fewer requirements needed. He says many more people can benefit from it in a short period of time, compare to the conventional surgical method.

“A healthcare provider can perform 15 surgical circumcisions per day compared to 60 PrePex procedures during the same period,” says Dr Lubega.
However, PrePex is recommended for adults over the age of 18, and should not be self-performed.
The medics say PrePex has been well received, since it does not require the use of anaesthesia, no blood loss is involved, and the procedure is painless. Dr Ngeruka cautions people intending to undergo the procedure to seek services of a trained PrePex provider, who usually carryout extensive counselling.

Cost of PrePex
In Uganda, Dr Lubega says one can get the PrePex at a cost of between Shs39, 000 and Shs52, 000.
He adds: “PrePex is tied to safe male circumcision campaigns being advocated for by the Ministry of Health, as an HIV prevention strategy.”

According to the Joint United Nations Programme on HIV/Aids, if 20 million people are circumcised by end of 2015, then roughly 3.4m lives, and $16.5bn will be saved in treatment costs.

International health experts are also pushing for the wide use of PrePex. “Nonsurgical devices such as PrePex can simplify the experience and reduce the burden of labour for health care workers in resource-limited settings,” says Eric Goosby, the US Global Aids coordinator.

circumcision facts in Uganda

The government officially started the free circumcision programme in September 2010 after promising results of randomised trials—in 2005 and 2007 — conducted in Uganda, Kenya and South Africa showed that medical male circumcision reduced the risk of contracting the HIV virus by up to 60 per cent.

This was then followed by the launch of an HIV/Aids policy that officially added circumcision to the traditional ABC-abstinence, faithfulness and use of condom approach.

The safe circumcision policy aims at providing circumcision to 40 per cent of Ugandan men aged 14-49 over a five year period.
Currently, only 25 per cent of Ugandan men between the ages of 15 and 55 years are circumcised, according to the Uganda Demographic and Health Survey.

Last year, the head of the Aids Control Programme in the Ministry of Health, Dr Alex Ario said PrePex would also be included as one of the prevention strategies under the medical male circumcision programme.